

<style>
.addurl_con {
	position: static;
	background: none;
}

.textw {
	vertical-align: middle;
}

.cashnote p {
	line-height: 24px;
	font-size: 12px;
	color: #6B6B6B;
}

.cashnote p strong {
	font-weight: normal;
	color: #FE9D40;
}

.addurl_con ul li label {
	width: 35%;
}

.addurl_con ul li {
	background: none;
}

.apply_wrapper {
	padding: 0 10px;
	background-image: url(/Static/mobile/images/apply_bg.png);
	background-repeat: no-repeat;
	background-size: 100% auto;
	background-position: 0 0;
	background-color: #f1f1f1;
}

.mlogin_but a, .mlogin_but button {
	width: 100%;
}

.addurl_con ul li .textw {
	background: none;
}

.apply_titimg {
	width: 100%;
	margin: 0 auto;
	padding: 20px 0;
}

.apply_titimg img {
	display: block;
	width: 40%;
	margin: 0 auto;
}

.cashnote {
	box-sizing: border-box;
	border: 1px dashed #bfbfbf;
	background-color: #fff;
	padding: 5px 10px;
	margin: 10px auto;
}

.cashnote p {
	font-size: 15px;
}

.apply_title {
	text-align: center;
	font-size: 36px;
	color: #ff8f09;
}

.subtitle {
	text-align: center;
	font-size: 15px;
	letter-spacing: 4px;
	color: #989797;
	font-family: SimHei;
}
</style>

<div class="membersbox pad50">

	<div class="apply_wrapper">
		<div class="apply_titimg">
			<!-- <img src="/PublicMob/images/apply_tit.png" width="40%" alt=""> -->
			<h1 class="apply_title">申请分销</h1>
			<h3 class="subtitle">快速分销拿幸福积分</h3>
		</div>
		<form action="" method="post" enctype="multipart/form-data" id="form1">
			<section class="addurl_con">
				<ul>
					<li class="clearfix"><label><b class="colorRed">*
						</b>申请人：</label><input type="text" name="agent_name" id="agent_name"
						placeholder="请输入您的真实姓名" value="444" class="textw"></li>
					<li class="clearfix"><label><b class="colorRed">*
						</b>手机号码：</label><input type="text" name="mobile" id="mobile"
						value="13027949433" placeholder="请输入您的手机号码" class="textw">
					</li>
					<li class="clearfix"><label>微信号：</label><input type="text"
						name="weixin_account" id="weixin_account" placeholder="请输入您的微信号"
						value="" class="textw"></li>
					<li class="clearfix"><label>选择地区：</label> <select
						name="province_id" class="selec j-province">
							<option value="210000">辽宁省</option>
							<option value="110000">北京市</option>
							<option value="120000">天津市</option>
							<option value="130000">河北省</option>
							<option value="140000">山西省</option>
							<option value="150000">内蒙古自治区</option>
							<option value="210000">辽宁省</option>
							<option value="220000">吉林省</option>
							<option value="230000">黑龙江省</option>
							<option value="310000">上海市</option>
							<option value="320000">江苏省</option>
							<option value="330000">浙江省</option>
							<option value="340000">安徽省</option>
							<option value="350000">福建省</option>
							<option value="360000">江西省</option>
							<option value="370000">山东省</option>
							<option value="410000">河南省</option>
							<option value="420000">湖北省</option>
							<option value="430000">湖南省</option>
							<option value="440000">广东省</option>
							<option value="450000">广西壮族自治区</option>
							<option value="460000">海南省</option>
							<option value="500000">重庆市</option>
							<option value="510000">四川省</option>
							<option value="520000">贵州省</option>
							<option value="530000">云南省</option>
							<option value="540000">西藏自治区</option>
							<option value="610000">陕西省</option>
							<option value="620000">甘肃省</option>
							<option value="630000">青海省</option>
							<option value="640000">宁夏回族自治区</option>
							<option value="650000">新疆维吾尔自治区</option>
							<option value="710000">台湾</option>
							<option value="810000">香港特别行政区</option>
							<option value="820000">澳门特别行政区</option>
							<option value="990000">海外</option>
					</select> <select name="city_id" class="selec j-city">
							<option value="210800">营口市</option>
					</select> <select name="area_id" class="selec j-area">
							<option value="210882">大石桥市</option>
					</select></li>
					<li class="clearfix"><label>详细地址：</label><input type="text"
						name="address" id="address" value="订单" placeholder="请输入您的详细地址"
						class="textw"></li>
				</ul>

				<div class="apply_agreement" style="display: none;" show="0">
					<br>
					<section style="word-wrap: break-word; word-break: break-all;"></section>
				</div>

				<section class="mlogin_but">
					<a href="javascript:;" class="J-addApply">确定</a>
				</section>

				<!--section class="mlogin_but" style="margin-top:10px;"><a class="call J-call" href="javascript:;">取消</a></section-->
			</section>
		</form>
	</div>


	<script src="__STATIC__mobile/js/agentApply.js"></script>